Related Experiment Videos
Management of isolated systolic hypertension
1Department of Clinical and Experimental Pharmacology, University of Adelaide, South Australia.
Insights
Isolated systolic hypertension (ISH) in older adults significantly increases cardiovascular risks. Lowering systolic blood pressure (SBP) through lifestyle changes and medication effectively reduces these events, improving patient outcomes.
Area of Science:
- Cardiology
- Geriatrics
- Pharmacology
Background:
- Isolated systolic hypertension (ISH) is the most prevalent form of hypertension in the elderly, affecting approximately 60% of individuals over 65.
- ISH is linked to substantially elevated risks of cardiovascular and cerebrovascular morbidity and mortality.
- The Systolic Hypertension in the Elderly Program (SHEP) study demonstrated that reducing SBP in elderly patients with ISH significantly lowers cardiovascular events.
Purpose of the Study:
- To review the evidence supporting the active treatment of isolated systolic hypertension in the elderly.
- To discuss the pathophysiological mechanisms and effective pharmacological interventions for ISH.
- To provide guidance on initial management strategies, including lifestyle modifications and drug therapy.
Main Methods:
- Review of landmark studies, outcome studies, and short-term clinical trials on ISH treatment.
- Analysis of the efficacy of various antihypertensive drug classes (diuretics, beta-blockers, calcium channel antagonists, ACE inhibitors, alpha antagonists).
- Consideration of patient risk factors and clinical context in treatment decisions.
Main Results:
- Lowering SBP in elderly patients with ISH demonstrably reduces cardiovascular events.
- Multiple antihypertensive drug classes, including diuretics, calcium channel antagonists, and ACE inhibitors, are effective in reducing SBP.
- Aggressive treatment is most beneficial for high-risk individuals, with SBP of 140-159 mm Hg indicating active management.
Conclusions:
- There is strong evidence supporting active management for individuals with SBP ≥ 160 mm Hg, and SBP 140-159 mm Hg in high-risk patients.
- Initial management should involve lifestyle modifications, with drug therapy considered if blood pressure targets are not met.
- Thiazide-like diuretics are a reasonable first-line option, but calcium channel antagonists and ACE inhibitors are also effective; combination therapy may be necessary.
Abstract:
Isolated systolic hypertension (ISH) [systolic blood pressure (SBP) > or = l60mm Hg with diastolic blood pressure (DBP) <90mm Hg] is the commonest form of hypertension in the elderly, and accounts for about 60% of all hypertensive conditions in the population aged over 65 years. It is associated with a significantly increased risk of cardiovascular and cerebrovascular morbidity and mortality. The landmark Systolic Hypertension in the Elderly Program (SHEP) study, published in 1991, has shown that lowering the SBP in elderly patients with ISH results in a significant reduction in cardiovascular events. These results have had a major impact on clinical practice in hypertension. On theoretical grounds, considering the pathophysiological mechanisms of ISH in the elderly, any drug which lowers total peripheral resistance and/or arterial stiffness should reduce SBP effectively in these patients. This effect has been observed in outcome studies and short term clinical trials using a variety of drugs from the 4 major antihypertensive classes: diuretics, beta(1)-blockers, calcium channel antagonists and ACE inhibitors. Other drugs, including alpha antagonists, may also be effective. In general, there is compelling evidence to support active treatment of any individual with an SBP > or = 160mm Hg. As in essential hypertension, the maximum benefit is gained by aggressive treatment of those individuals at highest risk because of coexisting cardiovascular risk factors. In these people, an SBP of 140 to 159mm Hg should be considered to be an indication for active management. Initial management should be by manipulation of lifestyle factors such as bodyweight, salt and alcohol intake and aerobic exercise. Drug therapy, generally well tolerated in low doses, should be considered if SBP remains > or = 160mm Hg, or > or = 140mm Hg in the presence of multiple risk factors. The choice of initial drug therapy should be influenced by the particular clinical situation. If there are no coexisting contraindications or co-indications for particular drugs, it is reasonable to begin treatment with a low dose of a thiazide-like diuretic, as used in the SHEP study. However, in short term treatment trials calcium channel antagonists and ACE inhibitors have been shown to lower SBP effectively and can be used in the appropriate clinical context. Beta-blockers appear to be less effective as monotherapy in ISH. Combination therapy is frequently required and can be effective and well tolerated if carefully chosen.